24 obat2 an

• Antibiotics have been excessively used
• Problems with excessive use of antibiotics

  • Treatment failure
  • Resistents
  • High costs
• Antibiotics are highly required due to high prevalence of infectious diseases
• Use of antibiotics


  • Human use (60%)
  • Agricultural use (40%)
• Human use of antibiotics

  • 20% Hospital
  • 20-50% Unnecessary
  • 80% Community
• Agricultural use of antibiotics

  • 20% Therapeutics
  • 40-80% Highly questionable
  • 80% Prophylactics/growth promoter
• Problems in the use of antibiotics

  • For non infectious disease (i.e common cold)
  • Pharmacokinetics & pharmacodynamics
  • Adverse reactions
  • Antibiotics resistants
  • Cost

  
• Inappropriate antimicrobial use


  • Prescription not taken correctly
  • Antibiotics for viral infections
  • Antibiotics sold without medical supervision
  • Without proper diagnosis
• Pharmacokinetics (PK)


  Plasma drug concentration, Penetration to site of infection
• Pharmacodynamics (PD)


  Susceptibility – MIC (potency), Concentration- vs. time-dependent killing, Persistent (post-antibiotic) effects (PAE)

  
• PK/PD parameters


  • T>MIC
  • Peak/MIC
  • AUC/MIC 24 jam
• Predictors for bacterial eradication


  • Peak/MIC
  • T > MIC
  • AUC/MIC 24 jam

  
• Drivers for the use and misuse of antibiotics

  • Cultural beliefs & traditions
  • Lack of appropriate knowledge
  • Untrained sources of advice
  • Marketing influences
  • Incorrect norms/models seniors
  • Economic factors & incentives
  • Fear of poor clinical outcomes
  • Patient/customer demand
• Principles of antibiotic action

  • Selective toxicity
  • Parenteral vs oral
  • Short vs long half-lives
  • Broad spectrum vs narrow spectrum
  • Bactericidal vs bacteriostatic
  • Combination of antibiotics
  • Short vs long antibiotic course

  
• Selective toxicity


  The drug must inhibit the microorganisms at lower concentrations than those that produce toxic effects in humans
• Therapeutic index


  The larger the ratio the safer the drug
• Advantages and disadvantages of oral administration

  • Advantageous: easy and less costly
  • Disadvantageous: Drug has to undergo a circuitous route to reach the site of infections, Some Abs passes to the lower bowel where some of the highest concentration of bacteria are to be found destruction of the commensal faecal flora lead to side effects (diarrhoea)

  
• Advantages and disadvantages of intravenous administration

  • Advantageous: Dependable and reproducible effects, Entire administered dose reaches the systemic circulation immediately, the dose can be accurately titrated against response
  • Disadvantageous: Requires a functioning cannula, More expensive and labour intensive than other routes, Cannulation is distressing to some patients, especially children, Cannulae are prone to infection, IV injection of drugs may cause local reactions
• Advantages and disadvantages of short vs long half-lives

  • Short half-lives: Should be given several times a day, If less adhere sub inhibitory concentration not efficacious
  • Long half-lives: Greater risk of adverse drug reaction, AB will persist in the body for many days following the end of therapy
• Advantages and disadvantages of narrow vs broad spectrum antibiotics

  • Narrow spectrum: Is usually to be preferred in the tx of infection when the infecting species has been identified
  • Broad spectrum: May be desirable for empiric therapy if the infecting organism has not yet been identified
• Combinations of antibiotics are used to overcome the presence or prevent the emergence of drug-resistant strains, and to broaden the spectrum, especially for empiric therapy
• The longer the course of antibiotics therapy, the greater the risk of developing resistance
• The longer the course of antibiotics, the greater the risk of low adherence and treatment failure
• Principles of antibiotics use for infections

  • Are the indications based on clinical findings?
  • Is there any findings from culture examination from proper specimen
  • What microrganisms are likely?
  • If antibiotics are required, which antibiotics must be selected?
  • Are antibiotics combination appropriate?
  • Are hosts factor considered?
  • How to use antibiotics appropriately?
  • What is the proper and adequate dose?
  • Does shift therapy is required given the result of the culture?
  • How long antibiotics must be prescribed?

  
• Indications for antibiotics use

  • Obvious bacterial infections
  • Localized infections
  • Probable bacterial infections
  • Viral infection

  
• Factors to consider when selecting antibiotics

  • Gram staining
  • Culture examination
  • Patient's age
  • Epidemiology
  • Previous culture findings

  
• Factors to consider when selecting antibiotics (cont'd)

  • Drug of Choice (DOC)
  • History of hyperensitivity
  • AB penetration and pH
  • Possible adverse events
  • Bactericid vs bacteriostatics
  • Cost of antibiotics
  • Narrow vs. broad spectrum

  
• Antibiotics combinations are used to reduce adverse events and risk of resistance

  
• Examples of antibiotics combinations

  • Penisilin + gentamisin: streptokokus dan enterokokus
  • Ticarsilin + aminoglikosida: P. aeruginosa
  • Cephalosporin + aminoglikosida: K. pneumonia
  • amoksisilin + clavulanic acid: beta laktamase
• Host factors to consider

  • Genetics
  • Pregnancy & lactation
  • Renal function
  • Liver function
  • Humoral & celular mechanism
• Antibiotics and pregnancies


  • Safe
  • Cautions
  • Contraindication
• Routes of antibiotic administration

  • Parenteral
  • IV
  • IM
  • Oral
• Antibiotic dosing in pediatric patients

  • Amikacin
  • Amoxicillin
  • Amoxicillin/clavulanic acid
  • Ampicillin
  • Azithromycin
  • Benzylpenicillin
  • Cefalexin
  • Cefazolin
  • Cefotaxime
  • Ceftazidime
• De-escalation of antibiotics is required to reduce selection of MDR bacteria, cost, and improve time to recovery and mortality

  
• Typical durations of antibiotic treatment

  • Meningitis meningokokus (7-10 days)
  • Meningitis pneumokokus (10-14 days)
  • Meningitis H. influenzae (10-14 days)
  • Faringitis Streptokokus grup A (10 days)
  • Otitis media (7-10 days)
  • Sinusitis bakterial (10-14 days)
  • Pneumonia mycoplasma (14 days)
  • Endokarditis (28 days)
  • Peritonitis (10-14 days)
  • Osteomyelitis (28 days)
• Empiric antibiotic therapy should use broad spectrum therapy if the patient is very ill, then modify based on culture results to use narrow spectrum, long-half life, low toxicity, inexpensive antibiotics

  
• Tools for good antibiotic stewardship

  • Guidelines
  • Restrictions
  • Area specific practices eg: ICU/ NICU / HDU
  • De-escalation
  • Combination Tx
  • Scheduled changes
  • Antibiotic or Crop cycling/ rotation
  • Computer assisted antibiotic prescribing

  
• The right antibiotic should be prescribed for the right patient at the right time with the right dose and the right route, causing the least harm to the patient and future patients

  
• Disadvantages of oral administration


  
  
• Low adherence


  When a patient does not follow the recommended treatment plan and may skip doses or stop taking the medication early